Application To Pay Less Than Minimum Wage To A Disabled Person

The Great Seal of the State of New Jersey

STATE OF NEW JERSEY

DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT

DIVISION OF WAGE AND HOUR COMPLIANCE

Application Information
**
Name of the company that is applying for permit
**
(Street)
(Address Line 2)
(City, State, Zip as nnnnn-nnnn or nnnnn)
Address of the company that is applying for permit
**
Type of business for the company that is applying for permit
**
(First, Middle, Last)
Name of the disabled person who the company plans to employ
**
(Street)
(Address Line 2)
(City, State, Zip as nnnnn-nnnn or nnnnn)
Address of the disabled person who the company plans to employ
**
(MM/DD/YYYY)
When the disabled person was born
**
-- (xxx-xx-xxxx)
The federal identification number from the social security administration for the disabled person who the company plans to employ
**
Name of disability for person the company plans to employ
**
Exact description of the job duties for the disabled person
How the employee will be paid in hours
How the employee will be paid weekly
How the employee will be paid. (for example in hotel industry for the number of rooms cleaned)
**
How much time the employee will work
**
How much time the employee will work
**
How much time the employee will work
**
The employees work history with the employer applying for the permit
**
Minors must have worker papers from the school they attend
**
(MM/DD/YYYY)
Date employment certificate is issued permit issued
**
**
**
**

(** indicates a required field)

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